Mutations and sequence variants in GDF9 and BMP15 in patients with premature ovarian failure

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European Journal of Endocrinology (2006) 154 739–744                                                                               ISSN 0804-4643

CLINICAL STUDY

Mutations and sequence variants in GDF9 and BMP15
in patients with premature ovarian failure
Paul Laissue, Sophie Christin-Maitre1, Philippe Touraine2, Frederique Kuttenn2, Olli Ritvos3, Kristiina Aittomaki4,
Nathalie Bourcigaux1, Laetitia Jacquesson1, Philippe Bouchard1, Rene Frydman5, Didier Dewailly6, Anne-Céline
Reyss6, Luke Jeffery3, Anne Bachelot2, Nathalie Massin7, Marc Fellous and Reiner A Veitia
INSERM 709, Genomics and Epigenetics of Placentary Pathology, Hôpital Cochin, Pavillon Baudelocque, 123 Bd de Port Royal, 75014, Paris, France,
1
  Reproductive Endocrine Unit, Hôpital Saint-Antoine, Faculté Pierre et Marie Curie, UPRESS 1533, 75012 Paris, France, 2Faculty of Medicine,
Université Paris V, Necker Hospital, APHP, 149 rue de Sèvres, 75743 Paris cedex 15, France, 3Program of Developmental and Reproductive Biology,
Biomedicum Helsinki, University of Helsinki, Helsinki, Finland, 4Department of Clinical Genetics, Helsinki University Hospital, Helsinki, Finland,
5
  Department of Gynaecology and Obstetrics, Hôpital Antoine Béclère, 92141, Clamart cedex, France, 6Department of Endocrine Gynaecology and
Reproductive Medicine, Hôpital Jeanne de Flandre, CHRU, 59037, Lille, France, and 7Department of Gynaecology and Obstetrics, Reproductive Unit,
Intercommunal Hospital, 94110 Creteil, France
(Correspondence should be addressed to R A Veitia; Email: veitia@cochin.inserm.fr)

                             Abstract
                             Background and objective: Mutations in bone morphogenic protein 15 (BMP15) and growth/differen-
                             tiation factor 9 (GDF9) lead to altered fertility in animal models. In the human, a heterozygous point
                             mutation of BMP15 has been associated with premature ovarian failure (POF).
                             Subject and methods: We have directly sequenced both genes in a cohort of 203 POF patients present-
                             ing with primary or secondary amenorrhea and high FSH levels and in a control population including
                             54 women with regular menstrual cycles who had at least one child.
                             Results: We have identified several heterozygous variants. One alteration in GDF9 (S186Y) and one in
                             BMP15 (L148P) may have pathogenic effects as both positions are conserved in vertebrate species,
                             ranging from the chicken to mammals. These variants were absent in the control samples. We also
                             found synonymous and neutral substitutions.
                             Conclusions: We propose that although mutations in BMP15 and GDF9 are not a major cause of ovar-
                             ian insufficiency, they may be involved in POF.

                             European Journal of Endocrinology 154 739–744

Introduction                                                                  Mutations in bone morphogenic protein 15 (BMP15)
                                                                           and its close autosomal paralogue growth/differentia-
Premature ovarian failure (POF) is defined as amenor-                      tion factor 9 (GDF9) are able to alter female sheep
rhea for at least 6 months occurring before the age of                     and mice fertility (12 – 15). Recently, a point mutation
40 years, associated with raised plasma gonadotrophin                      in BMP15 has been associated with POF (16). A 4 bp
levels (follicle-stimulating hormone (FSH) greater than                    deletion of GDF9 apparently leading to a premature
40 mIU/ml) (1). POF has a prevalence of 1%. Ovarian                        stop codon has been reported in two sisters with
failure can result from viral or auto-immune oophoritis,                   twins from one family (17). Furthermore, two missense
environmental toxins and iatrogenic causes such as                         mutations in GDF9 have recently been associated with
pelvic surgery, radiation or chemotherapy. Deletions                       POF (18). BMP15 and GDF9 (respectively located on
and translocations involving three extensive regions                       Xp11.2 and 5q31.1) encode soluble factors, which
of the X chromosome (i.e. Xq13–22, Xq26 –28 and                            belong to the transforming growth factor superfamily
Xp11.2 –22.1) have been associated with POF (2 – 5).                       (TGFb). TGFb proteins are involved in various develop-
In Turner’s syndrome, ovarian insufficiency is probably                    mental processes including reproductive functions
due to haploinsufficiency of pseudoautosomal loci of                       (19 – 21). In mammals, BMP15 and GDF9 are specifi-
the X chromosome (6, 7). Mutations in autosomal                            cally expressed in the oocytes in a similar spatio-tem-
genes (i.e FSHR, FOXL2, GALT) have also been related                       poral pattern throughout folliculogenesis (20, 22 –24).
to POF (8 – 11). Nevertheless, in most cases the etio-                        Both genes have two exons and encode prepropro-
pathology of the disease remains unknown.                                  teins composed of a signal peptide, a proregion and a

q 2006 Society of the European Journal of Endocrinology                                                                   DOI: 10.1530/eje.1.02135
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740     P Laissue and others                                                  EUROPEAN JOURNAL OF ENDOCRINOLOGY (2006) 154

mature peptide. The signal peptide region is encoded by     tux.embl-heidelberg.de/ramensky/index.shtml).           The
the first exon, the proregion by segments of both exons     SIFT software uses the protein sequence similarity of
and the mature peptide region by the second exon.           different species and the hydrophobic characteristics
Their biological activity depends on the formation of       of amino acids to calculate the probability of a deleter-
homo and/or heterodimers after proteolytic processing       ious effect of specific amino acid variants (28). Scores
(25– 27).                                                   lower than 0.05 suggest a potential pathogenic
   Here we have screened a cohort of 203 POF patients       amino acid substitution. The PolyPhen program offers
for mutations in GDF9 and BMP15. We analyzed the            information about the effect of the amino acid substi-
entire coding sequences of both genes by direct sequen-     tution by considering structural parameters and
cing. The variants were screened in a panel of 54           three-dimensional protein structures (29, 30). The
women with normal fertility.                                GoCore program version 5.0.1 (http://www.helsinki.
                                                            fi/project/ritvos/GoCore/) was used for performing mul-
                                                            tiple alignments of sequences from several vertebrate
Materials and methods                                       species including H. sapiens, P. troglodytes, C. familiaris,
Patients and control population                             R. norvegicus, M. musculus, S. scrofa, B. taurus, C. hircus,
                                                            C. elaphus, O. aries, T. vulpecula, D. novemcinctus, O. gar-
Women (203 subjects) were recruited from several            netti, M. mulatta, P. anubis, C. jacchus, M. domestica, G.
clinical centres: Reproductive Endocrine Units from         gallus and F. rupribes.
Hôpital Saint-Antoine, Hôpital Necker, Paris, France,
Hôpital Jeanne de Flandres, Lille, France, a gynaecolo-
gical unit in Hôpital Antoine Béclère, Clamart, France   Results
and the the Department of Obstetrics and Gynaecology
                                                            Sequence analysis
of Helsinki University Hospital, Helsinki, Finland.
Inclusion criteria were primary or secondary amenor-        The analysis of the coding sequence of GDF9 revealed,
rhea occurring before the age of 40 years, with an          in one case, a heterozygous transversion 557C . A
FSH serum level higher than 40mIU/ml. The group of          (second exon). This leads to the change S186Y in the
patients was composed of 83% of women of Caucasian          proregion. This variant was not found in any control
origin, 14.9% of African origin and 2.1% of Asian           (n ¼ 54). Furthermore, we found two rather common
origin (37 patients were Finnish). This study was           synonymous substitutions, 447C . T and 546G . A
approved by the institutional review board of the rel-      (summary in Table 1).
evant hospitals and all participants gave their written        We detected, in the first exon of BMP15, a heterozy-
informed consent. The control population included 54        gous transition G308A (with respect to the sequence
women with regular menstrual cycles (28 – 32 days),         AH007120 in Genbank). This variant appeared in
having at least one child and no personal history of        99% of the patients and controls. In the second exon,
infertility or auto-immune disease. Among these             six different variants were detected. In one patient, we
women 40 were of Caucasian origin and 14 of African         found the heterozygous 443T . C transition, leading
origin.                                                     to an L148P change in the proregion. We did not
                                                            find this variant in any control (n ¼ 54). Furthermore,
                                                            this patient presented an insertion of three base pairs
DNA extraction and sequencing                               (788insTCT) leading to the insertion of a leucine at pos-
Genomic DNA was isolated from whole blood samples           ition 263. Ins263L was found in nine other patients
using the standard phenol – chloroform procedure.           and in 16.6% (nine of 54) of the control sample. All
Both exons of GDF9 and BMP15 were amplified by              the controls presenting these variants were of African
PCR in all the patients (n ¼ 203). The second exon          origin. Among the patients showing this mutation
was amplified in all control individuals (n ¼ 54). PCR      60% were of African origin. A transition 588G . A
products were treated with shrimp alkaline phospha-         (A180T) was found in two patients at the heterozygous
tase and exonuclease I as described by the manufac-         state. This variant was not present in any control. In
turer (USB, Cleveland, Ohio, USA) and directly              addition, we detected three silent substitutions,
sequenced using an ABI 3100 sequencer (Applied Bio-         538G . A, 831T . C and 468G . A (Table 1).
systems, Foster City, CA, USA). The presence of each
variant was confirmed by a new round of PCR amplifi-        Patients’ phenotype
cation and sequencing.
                                                            BMP15-L148P The patient was a 30-year-old Afri-
                                                            can woman presenting with secondary amenorrhea.
In silico analysis
                                                            She was a second daughter of a non-consanguineous
To determine the potential deleterious effect of the        family. Puberty occurred when she was 13 years
amino acid changes we used SIFT (http://blocks.fhcrc.       old, with normal secondary sex characteristics
org/sift/SIFT.html) and PolyPhen softwares (http://         and breast development. The patient described initial

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EUROPEAN JOURNAL OF ENDOCRINOLOGY (2006) 154                  Mutations and sequence variants in GDF9 and BMP15 in POF                   741

Table 1 Results of the sequence analysis of BMP15 and GDF9 in 203 POF patients. The overview includes base substitutions at the
genomic level (numbering refers to the coding region), amino acid (AA) change, number of patients tested and allele frequency of each
variant.

Gene         Sequence variation         AA change         Clinical information       No. of patients         Frequency in population

BMP15        788insTCT                  Ins263L           POF                              203                      4.93% (10/203)
                                                          Controls                          54                      16.6% (9/54)
             443T . C                   L148P             POF                              203                      0.49% (1/203)
                                                          Controls                          54                         0% (0/54)
             538G . A                   A180T             POF                              203                      0.98% (2/203)
                                                          Controls                          54                         0% (0/54)
             852C . T                   S284S             POF                              203                      1.97% (4/203)
                                                          Controls                          54                         0% (0/54)
             831T . C                   T277T             POF                              203                      0.49% (1/203)
                                                          Controls                          54                         0% (0/54)
             468G . A                   V156V             POF                              203                      0.49% (1/203)
                                                          Controls                          54                         0% (0/54)
GDF9         557C . A                   S186Y             POF                              203                      0.49% (1/203)
                                                          Controls                          54                         0% (0/54)
             447C . T                   T149T             POF                              203                       75.9%(154/203)
                                                          Controls                          54                      55.5% (30/54)
             546G . A                   E182E             POF                              203                     23.15% (47/203)
                                                          Controls                          54                        26% (14/54)

oligomenorrhea. When she was 19 years old, she                       family. At the age of 35 years, a coelioscopy was per-
received the oral contraceptive pill (OC) until she                  formed showing atrophy of both ovaries. The ovary
was 29 years old but she stopped it frequently. She                  cortex biopsy was composed of interlacing bundles of
then became pregnant twice but interrupted the                       stromal spindle cells and contained some white body
pregnancy in both cases. When she definitely stopped                 remnants but there were no follicles on serial sections.
taking the OC, secondary amenorrhea appeared.                        After the initial diagnosis of POF, the patient received
When she was referred to our department, the                         hormone replacement therapy. We did not have
patient’s height was 163 cm and her weight was                       access to familial blood samples.
73 kg. Plasma FSH and luteinizing hormone (LH)
were high: 120 mIU/l (normal (N), 4– 8 mIU/l) and
100 mIU/l (N, 3 –12 mIU/l) respectively. Plasma oes-
tradiol and inhibin B were low: 30 pmol/l (N, 70 –
                                                                     Discussion
1000 pmol/l) and 15 pg/ml (N, 60 – 120 pg/ml)                        BMP15 and GDF9 play a key role in the molecular dia-
respectively. No anti-thyroid or anti-ovary antibodies               logue between the oocyte and the surrounding somatic
could be detected. The karyotype was normal.                         cells, promoting granulosa cell mitosis and cumulus
Pelvic ultrasonography showed a small uterus                         expansion by a paracrine effect (31, 32). They are syn-
(68 £ 39 £ 27 mm), an atrophic endometrium and                       thesized as propreproteins composed of a signal peptide,
very small ovaries in their surface (0.56 and                        a proregion and a mature peptide. As for many TGFb
0.64 cm2 for the right and left ovaries respectively                 factors, the proregion of BMP15 and GDF9 might be
(N, 2– 6 cm2). No follicle was observed. The patient                 necessary for a correct folding, dimerization and
received an oral oestrogen-progestagen treatment.                    secretion of the mature protein (19). In vivo, the biologi-
We did not have access to blood samples from any                     cal role of BMP15 and GDF9 in animal fertility has
family members.                                                      been demonstrated in mice and ruminants. Naturally
                                                                     occurring heterozygous mutations in BMP15 and
GDF9-S186Y The patient, of Caucasian origin, was                     GDF9 in sheep increase the ovulation quota leading
referred to us at the age of 37 years for primary infer-             to hyperfertility, whereas homozygous mutations pro-
tility. Menarche had occurred at 9.5 years of age with               duce infertile animals (12, 13). The biological effect of
regular menstrual cycles every 21 days up to the age                 the mutations in mammals varies among species (12,
of 33 years, then her menses suddenly stopped. At                    15). For example, GDF9 2/2 mice present a phenotype
that time, her FSH, LH and oestradiol serum levels                   that is similar to BMP15 homozygous sheep mutants
were respectively 104 mIU/ml, 46 mIU/ml and                          whereas BMP15 knockout (KO) mice have normal
, 20 pg/ml. Anti-thyroid and anti-DNA serum anti-                    ovaries and subfertility (15). The double gene KO
bodies were undetectable. No familial or personal his-               leads to infertility while other combinations of alleles
tory of pelvic surgery was recorded. Her height was                  display different phenotypes (15). The difference in
153 cm and her weight 60 kg. Her karyotype was                       the effects of the mutations could be explained
46XX. No other case of POF was identified in the                     by the intrinsic characteristics of mono-ovulatory or

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742     P Laissue and others                                                    EUROPEAN JOURNAL OF ENDOCRINOLOGY (2006) 154

polyovulatory species. Moreover, the mutations in mice        polymorphisms, 447C . T and 546G . A, in 154
are loss-of-function whereas in sheep and human there         (75.9%) and 47 (23.1%) respectively of our POF
are presumed to be dominant negative. Indeed, in vitro        patients. These variants are common polymorphisms
cell transfection assays using constructs corresponding       in diverse ethnical groups since they have also been
to the natural mutations observed in sheep demon-             described in Indian POF patients (18).
strated that dominant negative interactions between              The sequence analysis of BMP15 revealed that the
these factors have an important effect on the secretion       heterozygous transition G308A (S103N, with respect
of the mature peptides (27). In the human, a heterozy-        to Genbank AH007120) that appeared in the first
gous point mutation of BMP15 that has been associ-            exon is in fact the most common allele. One patient car-
ated with POF (Y235C) is located in the proregion             ried a 443T . C transition at a heterozygous state in
and in vitro experiments have shown a diminished              the second exon. This leads to a L148P change at the
stimulatory activity of granulosa cell mitosis by a           protein level. This mutation was located in the prore-
potential dominant negative effect (16). Recently, two        gion, closer to the N-terminus than that described by
missense mutations (K67E and V216M) located in                Di Pasquale et al. (16). The ovarian phenotype of the
the GDF9 proregion have been described in Indian              patient with the BMP15 mutation was less severe
POF patients and could be implicated in the ovarian           than in the two cases previously described (16). A mul-
phenotype (18). Sequence alignments have shown                tiple sequence alignment showed that the amino acid
that the first variant is not likely to have any functional   L148P position was also conserved across vertebrates,
relevance since in the sheep and the chicken the K resi-      from chicken to mammals, suggesting a crucial func-
due is replaced by an E. In the second case, the amino        tional or structural role. As expected, both Polyphen
acid V is well conserved or replaced by a highly hydro-       and SIFT programs suggested a potential deleterious
phobic residue which argues in favour of a functional         effect. The substitution L-to-P translates into an
impact. The results using SIFT are in agreement.              important change in hydrophobicity (L . P) and rel-
   In our cohort of 203 patients, we identified two novel     evant modifications in terms of structure. The presence
heterozygous missense mutations, one in each gene,            of a P might change the rigidity of the peptidic chain
that could be implicated in the ovarian phenotype.            and could alter protein folding itself or its kinetics.
Sequencing of GDF9 revealed the mutation S186Y                   The mutation A180T, found in two patients, is not
found in one patient with secondary amenorrhea.               likely to be deleterious as suggested by the SIFT and Poly-
The absence of this variant in women with normal              Phen programs. Although we did not find it in any con-
fertility suggests a potential pathogenic effect. This        trol, the Thr appears in wild-type sequences from C.
was further corroborated by the evolutionary conserva-        hircus and O. aries. The insertion of a leucine in position
tion of the S186Y in 17 vertebrate species, ranging           263, found in ten patients, probably has a low biological
from chickens to mammals (Fig. 1). Accordingly,               impact, as suggested by its presence in 16.6% of the con-
both the SIFT (score ¼ 0.03) and PolyPhen predictions         trols (nine of 54). Furthermore, it is present in rodents
suggested a deleterious effect. We also found two             and the marsupial T. vulpecula (Fig. 1). It is interesting

                                                                                Figure 1 Multiple protein sequence align-
                                                                                ments of BMP15 and GDF9 between mam-
                                                                                malian species displaying the regions of the
                                                                                second exon surrounding human mutations.
                                                                                Residues that differ from the wild-type (WT)
                                                                                human sequence are shaded in gray.
                                                                                Mutations found in the study are shaded in
                                                                                black. Dotted boxes highlight the positions of
                                                                                each variant.

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EUROPEAN JOURNAL OF ENDOCRINOLOGY (2006) 154                       Mutations and sequence variants in GDF9 and BMP15 in POF                     743

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